“Personal and Professional Reflections on Suspected Fetal Growth Restriction” – with Dr. Mariam Naqvi

Dr. Naqvi: Hey, welcome to the “Healthful Woman” podcast, the fastest-growing podcast in women’s health. Today’s Monday, August 28th, 2023. Last week and this week, we’re focusing on fetal growth restriction, sometimes called IUGR or intrauterine growth restriction. It’s a common concern in pregnancy where we think the fetus is measuring smaller than we would expect. Last week, we redropped a podcast, Simi Gupta and I did, in 2020 on this, and today I’m going to be joined by Dr. Mariam Naqvi.

Mariam is a maternal-fetal medicine specialist practicing in Los Angeles, and we worked together for several years in New York City. Mariam is both an expert in the diagnosis and management of suspected IUGR, but she is also someone who had suspected IUGR herself when she was pregnant with her first. So she’s going to be giving her personal and professional reflections on this important topic.

All right, bunch of reminders. First, if you’re listening on Apple or Spotify, please do rate us, preferably five stars. Please do leave comments. Second, please send us questions you might have for our mailbag. We recorded our third. It’s going to drop in September. The more questions you send, the more mailbag podcasts we’re going to do. Again, to send them in, you can email us directly at hw@healthfulwoman.com or you can go to our website, www.healthfulwoman.com, and click on the link that says send us your questions. Also, if you’d like to pre-order the book Emily Oster and I wrote, “The Unexpected,” we have a link on our website, so please take a look at that. Finally, as Labor Day weekend is coming up, reminder, to all of you who might be pregnant patients of our practice, we are moving hospitals. So, as of September 1, the place to be is Sinai West.

All right, thanks for listening. See y’all next week.

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At Healthful Woman, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Mariam, welcome to the podcast. It’s so good to have you as a guest. How are you doing?

Dr. Naqvi: I’m doing great. Thank you so much for having me.

Dr. Fox: This is so exciting. A, I get to speak to you, which is nice, just straight up, which is wonderful, and all the way in California. We miss you. We miss you out here.

Dr. Naqvi: I miss it all the time. I mean, it’s nice to be back home, but those years in New York together were a blast. I learned so much, and it was just great to get to know all of you so well.

Dr. Fox: It’s good. So for our listeners, you are Dr. Mariam Naqvi. You’re an associate professor, good job, of OB-GYN and MFM at Cedars-Sinai in Los Angeles. So how is Cedars-Sinai treating you?

Dr. Naqvi: It’s fantastic. It’s great. I always tell people I went from one Sinai to another, at Mount Sinai before, now I’m at Cedars-Sinai. It’s been really great. It’s funny because I always think of myself as a Californian, but I spent so much time on the East Coast, when I was in Boston and then New York. There’s still a transition coming back, but I can’t complain about the lovely winters here. And the medicine is pretty much all the same, so.

Dr. Fox: Babies still come out the same way on the West Coast as the East Coast.

Dr. Naqvi: You know, they really do. They really do.

Dr. Fox: Remarkable. The consistency of humanity, it is remarkable. Biology stays the same. So tell us a little bit about yourself. You mentioned California, where you’re from originally, and how you went through your medical training.

Dr. Naqvi: Sure. So yes, I grew up in Northern California, in the Bay Area. I actually went to college at UC Berkeley, which is only relevant because, ultimately, I ended up doing my residency at Stanford. And so very much a Bears fan. But let’s rewind. I just thought the Cal-Stanford thing is very, very important to make clear right from the bat.

Dr. Fox: Okay, noted. Duly noted.

Dr. Naqvi: For all my fellow Cal Bears out there. But yes, I did medical school at Irvine. That was when I first moved to California, back up to the Bay Area for residency. And then I did my fellowship in Boston, at Massachusetts General Hospital, which was the first time I lived on the East Coast. That was just such a tremendous experience. And I got to work with amazing folks out there. And then stayed on the East Coast. My first job at a fellowship was with you all, at Maternal Fetal Medicine Associates. So thanks for that. Thanks for hiring me. That was such a great experience. I mean, you all know it’s such a busy practice out there, and you take care of such a diverse group of women. And we’re really passionate about doing research when I was a fellow, and especially when we worked through you and Andrei Rebarber. We got to continue to do that while working together in New York.

So that’s sort of how I ended up there. And then I had my first baby, Layla [SP], when I was in New York, and that kind of was a big part of what brought us back to California because both my husband’s family and my family are over here. We got a little bit nervous about all sort of our new chapter in life, taking care of the newborn with pretty much no family around. So we came back to California, and I’ve been at Cedars-Sinai ever since.

Dr. Fox: Amazing. Now, we did sort of plant a seed in you when you were at Stanford because we sent our emissary, Yair Blumenfeld, to Stanford just to have him focused on the West Coast to sort of talk about us and say how wonderful we are. I think we paid him a commission, and so we’re getting a lot of Stanford people showing up, knocking on our front door for jobs and fellowships, and whatnot. Obviously, you worked with Yair. Did you hear about New York and Mount Sinai from him? Did he tell the tales of the psycho stuff going on out here?

Dr. Naqvi: Yes, he very much did when we were residents, and that was one of the things that I knew of him when we first met. And actually, that’s probably one of the first ways I actually heard about your name. And then you probably don’t remember this, but we met first I think it was my first year fellows retreat.

Dr. Fox: That makes sense.

Dr. Naqvi: I can’t remember. Was it really? And I think it’s in upstate New York.

Dr. Fox: It was either on the Palisades, technically. I think it’s technically New Jersey, or it could have been in Chicago. It was in two places around that time.

Dr. Naqvi: Maybe it was in Chicago. Oh gosh, now, I can’t even remember. But that’s the first time we met because we were assigned to sit at a table together. And I mean, I knew you, but you didn’t know me because you were already very big-time.

Dr. Fox: I was a big I was a big-time loser in that room, let me tell you.

Dr. Naqvi: So not true. So not true. In fact, even when I was telling folks that I was going to do the podcast, all I had to say is, you know, “I’m getting to do a podcast with Natie Fox.” It’s like, “Oh, gosh, Natie Fox.” Like, we all know Natie Fox. Everyone knows Natie Fox.

Dr. Fox: Oh, dear. Oh, dear.

Dr. Naqvi: So, yes. That was the first time we met.

Dr. Fox: And then what made you come all the way to Mass General? Is it just because you could tell people you went to Harvard? Is that really, like, that’s it, just that reason, or was there something that drew you specifically to come all the way out to Boston for fellowship? That’s a big deal, right? You’re born and raised in California, did undergraduate, medical school, residency. It’s all California. And now you’re going literally across the country to Boston just so you can put Harvard on your CV.

Dr. Naqvi: You are hilarious. I’m not going to lie, that was a perk, but not at all the reason that I managed to get there. You know, it was…well, A, let’s remind everyone that it is [inaudible 00:08:03], and I was very, very lucky to end up where I wanted to go. But when I was applying, Yair actually was a huge mentor to me because he…it was funny at the time. I remember asking him, “Okay, like, where should I apply?” And then he gave me a bunch of programs. And then, when I was trying to make my request, kind of hoping he was going to tell me, “Hey, maybe you want to put Stanford up there,” but he advised me when I was a resident to really try to train somewhere else. And it was the best advice I ever got. I mean, having been at different places for medical school, residency, fellowship, and now even practice, I mean, I just think he gives such a balanced and often sort of practical view of what medicine is like, and you kind of realize there’s so much nuance to what we do. And a lot of it matters, but a whole lot of it doesn’t.

So I think that was really what kind of drove me to even apply out of state. And then when I was looking at programs, I just had kind of places where I have some extended family or some version of that. So it wasn’t totally, totally foreign. And in Boston, I do have a bunch of cousins out there. And, you know, it’s like dating. Like, we interviewed, it clicked, I got along, you know, really well with the faculty there. And many were doing work that I was interested in. So I mean, the chemistry just felt right, and I was lucky enough to end up where I wanted to be. And it was the right decision in the end.

Dr. Fox: And I don’t know if…I don’t remember. I’m sure I asked you at the time. But then why did you come out to New York? I mean, was it just because of the glory of working with Andrei Rebarber? Was that it?

Dr. Naqvi: Well, you know, we were…at the time, you know, I wanted to stay. I wanted to be on the East Coast, and I was looking primarily in New England. And again, some of the drivers were places where I did have family, and it was very similar. You know, I interviewed up with you guys. It was a really nice kind of mix of being really busy clinically and getting to do research. I think for that first job at a fellowship, I mean, it’s fun really for me to say this now because I’m on the other end, but being really busy those first two years I think helped, you know, a lot because there’s a lot of skills you really want to solidify, and certainly, that practice is a great one. So I think, you know, it’s a lot of things that I wanted, and geographically, it just worked out.

Dr. Fox: Yeah. I mean, listen, I agree. I always tell people that I learned more in the first year in practice than I did in three years in fellowship. It’s just there’s so much, you know, going problem to problem, patient to patient, like, you know, topic to topic. You’re just knee-deep in it, and there’s nothing like that that you get in fellowship. I mean, residency, you’re really busy, but going into practice is so much more rigorous than your fellowship. Fellowship is usually kind of fluffy.

Dr. Naqvi: Oh, absolutely. And you know, sometimes it just…well, I don’t know. I was very grateful for my fellowship, and I know we’re all doing the best we can, but it’s definitely really busy a lot of the time. What we’re doing is clinical on both ends.

Dr. Fox: Yeah. No, I don’t mean fluffy, like, in a bad way. I mean, like, 50% of your time is research. And so you’re sitting at a computer, you’re doing charts, you know. It’s great, and it’s important. But, like, when you’re in practice, you’re 100% busy and doing the same thing also, even clinically. You’re talking, you’re giving lectures, you’re going to meetings. There’s a lot of stuff in fellowship that you don’t really do in practice or you don’t have an opportunity to do in practice. But I can say, since we’re both on the other end of it, we loved you immediately, thought you were awesome. We’re happy you worked with us. It was great. We’re very sad when you left us, but we understood. But we do appreciate that you’ve definitely…again, it’s like we sent another emissary out west. You sent us Faarnaz Kia, which was great. She’s awesome. And you know, Samantha Do came from Stanford, another Yair recruit. And so we’re very pleased with this outpost we have in Northern and now Southern California. So it’s pretty cool. So, wow, that’s great stuff.

Now currently, what kind of work are you doing at Cedars-Sinai? Are you busy doing deliveries? Are you sitting in the lab doing bench work? I mean, I know the answer to this, but our listeners don’t. What are you doing day to day?

Dr. Naqvi: Sure. Now, I do a little bit of everything. Actually, quite similar to what I was doing in New York but maybe a little bit more time with teaching and research. So if I kind of split up my work, I spend most of my days in the ultrasound unit, doing ultrasound on pregnant women, doing procedures, CVS, amniocentesis, and consultations. And then the other hat is really the education piece. I’m the clerkship director for our medical students that rotate over here at Cedars. And so we have, lucky enough, to have the UCLA medical students come spend four weeks with us at a time. And so I run that clerkship and get to do a lot of fun things with them. That’s a really cool part of my week.

And then I work really closely with the residents and our fellows. We have a fellowship here, and so part of what I do is mentor them through their research projects. I’m on the labor floor once a week. So every Monday, I’m it. If you show up at Cedars and don’t have a Cedars doctor, you’re stuck with me. And that’s really a fun part of the week because I do love deliveries. And part of being an MFM, these jobs kind of vary from practice to practice. And some groups like yours, right, do a lot of deliveries and get to stay really clinically active on the labor floor. And then there’s others that haven’t done a delivery in, like, 20 years. So that part was really important to me to keep that part of my skill set up, and it’s still probably one of the favorite parts of my job. So I do that about one day a week.

Dr. Fox: That’s awesome. It sounds like a really good…that’s a good job. I like that.

Dr. Naqvi: It’s a good balance, yeah.

Dr. Fox: All right. Well, you know, weather’s good. All right. We’ll talk offline. Sorry, everyone, we’re going out west. It’s going to be like on “Grey’s Anatomy” when everybody went from New York to Seattle for whatever reason they went out there. We’re moving. So when we were in touch about topics other than just catching up, you mentioned IUGR, intrauterine growth restriction or fetal growth restriction. And you mentioned, obviously, it’s a very interesting topic. It’s an MFM-y type of topic. It’s very common. But also you have some personal experience with this.

Dr. Naqvi: I do. I do. So, you know, well, as you very much know, my first daughter, Layla, when I was pregnant with her in New York, she had suspected growth restriction or small for gestational age or whatever you want to call it, which was diagnosed around…gosh, I have to think back, but probably 28 to 30 weeks. Initially, she was measuring a little bit small. I guess, for our listeners, I’m not the largest gal either. I’m a pretty petite person. So I expected my kid to also be on the smaller side. But she was always kind of in that 10th to 20th percentile range. And, you know, we really get worried about growth restriction when it falls maybe under the 10th, probably further than that. And then probably around 32 weeks, 32 to 34 weeks, she dropped to under the 10th percentile, ultimately. Actually, it was under the first percentile, I don’t know if you remember this, around I think probably 34 to 35 weeks. You may have even read my scans.

I remember I had my ultrasound done. It was at our 90th Street location. I’m a patient. And I had patients that afternoon, and I had my ultrasound, and it was like every number on that screen was reading less than the first percentile, like, that’s from the top to the bottom. And I remember I was like, “I might need to go for a little walk for my afternoon,” because I was really… I mean, even knowing what I know and knowing that everything else on that ultrasound was really, really reassuring, she was very really small. So, yeah, I remember I went to the little French restaurant, actually, across the street. I don’t know. Is that still there?

Dr. Fox: The restaurant across the street, I don’t know. There is a restaurant. There’s a different one. I’m not sure if it’s the same one.

Dr. Naqvi: I was really worried about that one during COVID. But in any case, I remember I walked over there, my husband met me for lunch. We had this cauliflower soup and was like, “Gosh, she’s actually really small. And I know she’s fine. And, you know, they told me the fluid is okay and really healthy otherwise. I’m really short.” Like, “It’s going to be okay.” But yeah, I was really worried. And, you know. Anyway, fast forward, I’ve been delivered at 38 weeks, and, of course, it was a totally fine delivery. And she did great, and she’s now 4 years old and 50th percentile for everything. Actually, she’s kind of on the taller side. So she’s probably tall and medium, skinny, I guess. But size-wise, there’s not been an issue since probably, like, three months. And she’s fine.

So, you know, the reason we’re now going back to topics, like you said, you know, fetal growth restriction, FGR, IUGR, it’s such a common thing that we all see as maternal-fetal medicine specialists. But I will say that having kind of gone through that process, it definitely has altered, I guess, how I counsel patients now, you know, when I see them in the office. And some of the questions that I used to kind of not have, like, the best responses to because I didn’t really know practically what all of it really meant, you know, I think that, yeah, going through it really helped that a lot.

Dr. Fox: What was her birth weight ultimately of 38 weeks?

Dr. Naqvi: She was 4 pounds, 11 ounces.

Dr. Fox: Yeah, little, little tiny thing. Who delivered her?

Dr. Naqvi: So it was Lisa Jackson who is just down the street from our office. But not without calling in some buddies from our practice. I don’t know if you remember the details of my labor report.

Dr. Fox: No, I don’t.

Dr. Naqvi: I was in due at 38 weeks, and then the induction went fine. And then, finally, when I was around like, I think, 9 centimeters dilated. We monitor all of our babies continuously in labor. We monitor heart rate. And Layla’s heart rate was…I mean, it was just dropping over and over and over again, having deceleration repetitively on the fetal heart monitor. And Lisa was thinking, “Okay, you know, you’re at mid-nine for a little bit. The tracing is getting not so great. You know, we’re probably going to have to move towards a C-section.” And I was like, “Okay, whatever, fine, you know. Whatever you think is best.” And, you know, it was 5:00 in the morning, and I called Bender. I called Dr. Bender. And I think, maybe I called…I definitely texted Rebarber or texted Bender, but they both showed up.

Dr. Fox: Can you come and bring a pair of forceps with you?

Dr. Naqvi: I don’t know. You know, I just felt like I needed my extended family around or something. And one of them must have been assigned to the labor for that day anyway. I’m trying to, like, make it sound better.

Dr. Fox: Trying to make yourself sound better than texting them middle of the night, “Please help.”

Dr. Naqvi: Totally. So, yeah, I was like…and I don’t even know why I called them. Like, I don’t know if it was…did I want them to, like, assist the C-section? Did I want, like, an opinion? Did I just want someone to, like, hold my hand? I don’t know. I was just, like, so freaking out. But they came, and I remember, it was actually just so nice to have everyone around and like, “Yeah, you’re fine. Everything’s fine. Like, you’ll push this baby out. It’s not gonna be a big deal at all.” And even Lisa was like, “Yeah, I’ve been so chill. It’ll be all good.” And then I think they pushed her out, like, the next hour. I pushed for 40 minutes, and it was a really uncomplicated delivery.

Dr. Fox: So small mom, small baby, and three tall doctors. Because Lisa is like an athlete. She’s like, you know, six feet tall. It’s like so terrifying, you know. She’s like…it’s crazy. I will say, parenthetically, for our listeners, when you said that you’re not a large person, in our practice, we used to use Naqvi as a unit of measurement. So we were describing a person, we would say, “Is she like 1.5 Naqvis? Is she 2 Naqvis? Is she 4 Naqvis?” I would say like, “My right leg is one Naqvi,” you know. And literally, just, it’s like a pound or a dozen or whatever it is. We just had a Naqvi as a unit of measurement because you’re the smallest one we had.

Dr. Naqvi: Yes, I am not mad about that.

Dr. Fox: It still happens.

Dr. Naqvi: You know, I have…

Dr. Fox: At Thursday morning meetings, someone will still say like, “Yeah, you know, she’s like 2 Naqvis.” And someone will be like, “What the hell are you talking about?” You know. “What is that? Is that British?”

Dr. Naqvi: [inaudible 00:21:10] is probably like, “What?”

Dr. Fox: “What? What is that?” You know, we have strange traditions that we maintain. Listen, you mentioned sort of the fear. I’m trying to get a sense. You know, hearing about fetal growth restriction can obviously be very scary for the patient’s side because, you know, we tell people, usually, everything’s fine, and occasionally, it’s not, right, which is…that’s unsettling, obviously. I want you to go a little bit into that when you said that, even though you sort of knew, it was still like concerning. How much of your thoughts were, “I know what’s going on. I do this every day. She’s going to be fine,” versus, “Oh my God, I’ve seen when this can go wrong,” right? Because it could go in either direction. Having the experience and knowledge can make it a lot better than average or can make it a lot worse than average. Which way do you think it went for you?

Dr. Naqvi: Right. You know, it seriously depended on the day of the week. I would say it was like 90-10. Like, 90% of the time, I knew it was going to be okay, you know. I was being seen twice a week, you know, to make sure the fluid around her was okay and her heart rate was fine, and all those kinds of things. So, you know, I would say most…and, you know, we see this clinically all the time. So that part of my brain was the dominant part, but there was definitely, like, 10% of the time, I did think about the scary things. And for me, it was more, you know…I was mostly concerned about, you know, she’s really small. She’s going to probably have to go to the neonatal ICU or the NICU, and I’m going to have to get separated from her. And gosh, that’s going to impact breastfeeding. I was really thinking a lot of those types of things and maybe less so of the more serious complications that can happen.

But, you know, all those things kind of crossed your mind. And I think I was, in a sense, I’m glad I was more reassured than not. But, you know, I’m human and sometimes, you know, it’s like…I remember being pregnant and seeing patients, right, who are in similar scenarios as you are and sometimes don’t have the best outcomes right in front of your eyes. And you’re just, you know… I remember I would just have that thought like, “Gosh, oh, yeah. Like, that could happen, too,” you know. And so I would say a little bit of both.

Dr. Fox: Okay. Were you the type of person who…as an OB and an MFM, were you micromanaging your own care or are you someone who’s just able to, like, let go and give it to others to take over?

Dr. Naqvi: I think, I don’t know. Maybe you need to ask my doctors. I think that I didn’t micromanage that much. I mean, I did, you know… I do remember knocking on your door and asking you if I should deliver earlier, and you said no, and I said, “Okay, fine.”

Dr. Fox: No.

Dr. Naqvi: So, you know. So I think I was a pretty good patient. I guess it’s easy for me sometimes, now, especially, when I have kids too, like, I don’t know if this is how you are with your kids, but I don’t know. My medical knowledge goes out the window when I take my kids to the pediatrician. I’m sort of like, “Just tell me what you think. Tell me what I need to do.” And it could be as simple as, like, a common cold, and I just need someone to give me their advice. And I think when I am a patient, which now I have been three times over with my three kids, I do get more into that role. So, I guess I don’t trust myself, let me put it that way. I’m worried I’m going to make the wrong choice if it’s myself because I’m just going to be so biased by all kinds of things. So, no, I think I’m a pretty good patient. I usually listen to what they tell me to do.

Dr. Fox: Yeah. I mean, my recollection is you were pretty chill despite everything that was going on. So I don’t have any recollection of being like, “Man, will she just, like, butt out of her own care?” Like, nothing. Nothing like that, which is good. With my own kids, I would say, generally, I am hands-off. Like, when my wife was pregnant and we were having kids, I was mostly…I was far less trained in, you know, I was in med school, and I was just in the beginning of residency, and even in fellowship. I was pretty hands-off, say, with my kids. But I would say that’s not necessarily because I would always be that way, but I trusted her doctors. I trust my kids’ pediatricians. Meaning, for me, if I’ve sort of come to the realization this is a doctor I trust, I’m a totally good butt and out, you know. Whatever you say is fine. If there’s a choice, let me know. Otherwise, whatever you say, I’m good.

But if I’m sort of engaging for the first time, like, if you’re in an emergency room or if you’re a new doctor, I’m always a little wary of, like, “Do I think this person knows what the hell they’re talking about?” And usually, it’s yes, and I’ve been mostly pleased. But every now and again, I’d be like, “Maybe we should do something else.” And that’s tough, obviously, because, you know, you don’t want to be that person. But on the other hand, you also want to be savvy and realize if they really are an expert or if they have your best interests in mind, or whatever it might be. You know, it’s tough. It’s hard.

Dr. Naqvi: Right. No, you’re so right. I totally agree. Because as you’re saying that, I’m thinking of all the time that I’m like, oh gosh, if anyone in my family, like, [inaudible 00:26:24], “Are you serious?” Like, you’re just, like, the worst when you see a new doctor, which is true. I mean, you know, I don’t even know if I told you about this, but you know, when Layla was three months old, I had a car accident. I was hit by a drunk driver, and right near Stanford, actually.

Dr. Fox: Oh, I did know this. Yes, I did know this.

Dr. Naqvi: Yes. And it was, like, the first time I had left my house, literally. I was picking up a car seat from a friend’s house. Actually, I just had dinner with Julie, Julia Romero, one of our other partners.

Dr. Fox: The other one who fled to California.

Dr. Naqvi: Exactly. It was, like, mama’s first outing. And so I had dinner with her and was on my way to go grab my car seat from a friend’s house, and then I was hit on El Camino Real by a drunk driver. I was taken to Stanford. I still remember being in that ambulance, and they wouldn’t give me any, like, pain medication. I actually had broken my wrist and broken my clavicle, and it really hurt. And I was like, “Well, like, maybe some like way we can get an IV in.” I was like, “Yeah, just give me something stronger, like, right now. I’m fine.” And they were like, “Well, I mean, you had said that you’re…” because they do do a quick history, and they asked me. I told them I was breastfeeding, and they were so nervous to give me medication because the best…and I’m like, “Are you…like, clearly, I’m not breastfeeding. I need [inaudible 00:27:45].”

Dr. Fox: Right. I’m not doing it right now.

Dr. Naqvi: Gosh, I feel really, really terrible. I’m sorry to whoever was in that ambulance, paramedic. I’m super grateful for your care. But yes, I do remember being pretty, like, directive.

Dr. Fox: “I’m a maternal-fetal medicine specialist. Give me my damn morphine.”

Dr. Naqvi: Totally. Yeah. Same thing in the emergency room. You’re so right. When you’re meeting someone for the first time and you don’t have that established rapport yet, then I feel like, yes, sometimes being a physician-patient. I don’t know. Kind of, like, you’ve got to feel it out a little bit. And then I think that’s when my medical brain definitely does turn on. And then, conversely, when a doctor I trust and know, it kind of takes the backseat.

Dr. Fox: And it’s the same way also, like, if you’re a doctor and the patient comes and one of them is a doctor, it changes the whole conversation. And again, you’re sort of balancing. You want to, on the one hand, not assume they know anything, right? You don’t want to…because they might not. So you start from the beginning, and you work your way up. But you also, on the other hand, want to, like, acknowledge like, “This might be a review for you,” or, “I’m sorry if this is basic for you, but we’re going to work our way up.” And it’s just a very different dynamic, which is always why I kind of feel that people just walk in the room and say, “Listen, I’m a cardiologist,” you know. Let’s just put it all on the table there because, occasionally, you go through the whole thing at the end. They’re like, “Dude, I’m a trauma surgeon.” I’m like, “Oh, thanks. Why tell me now?” “We have this thing called the scalpel and we use it.”

Dr. Naqvi: Right, right, right. Gosh, yeah, definitely. I love when it’s on the table because…it doesn’t even have to be medicine. Sometimes you just have, like, a researcher in genetics and you’re about to talk to them about genetic testing or whatever it is. People come in so many different backgrounds, and you never know what their expertise is. So, yes.

Dr. Fox: Yeah, it’s…

Dr. Naqvi: Good thing to feel it out.

Dr. Fox: So, I want to get a little bit into growth restriction itself, you know, because we definitely want to talk about that. We did a full podcast on it years ago with Simi Gupta, and so, you know, we can refer to that also. So we don’t have to cover everything here. But how would you just explain to our listeners what it is? Like, what are we talking about here? What’s going on with fetal growth restriction or IUGR?

Dr. Naqvi: Right. So, you know, I think, actually, as common as it is, it’s sometimes, I feel like, a challenging thing to discuss. I mean, you know, what we’re worried about with fetal growth restriction, which is something that we diagnose really by ultrasound, and so, kind of think about it, most patients are having an ultrasound in the first trimester, and most patients are having an ultrasound at somewhere between, you know, 16 to 20 or 18 to 20 weeks for an anatomy ultrasound. And then many patients who are, you know, I guess, “lower risk” may not necessarily have an ultrasound, right, for the rest of their pregnancy.

But, you know, in the OB provider’s office, I would keep an eye on the size of the baby, whether they’re measuring the belly with a little measuring tape or you’re getting ultrasounds in the ultrasound unit. And what we’re really screening for is, does the baby measuring appropriately [inaudible 00:30:58]? Like, are they measuring really, really big or measuring more than average? And so, you know, the definition that we kind of use for…I always like to say suspected fetal growth restriction, you know, because fetal growth restriction kind of implies there’s a topology, right? Like, that implies there’s something wrong. And the reality is most babies that are measuring on the smaller side don’t have anything wrong, right? They’re just on that part of the curve, so.

Dr. Fox: Right. They’re just1 Naqvi. They’re just 1 Naqvi. That’s it.

Dr. Naqvi: There you go. There you go. [inaudible 00:31:31] Yeah, we typically use a definition of the 10th percentile, and so what we do is we take, by ultrasound, at least, we take a bunch of measurements of the baby, of the head, of the abdomen, of the femur bones. Those are part of the equation and then plotted on some established growth curves. And, gosh, even that’s a whole other podcast episode, right, this domain of growth curve. But if the overall fetal weight estimate is measuring under the 10th percentile, then we sort of run with this diagnosis of possible or suspected growth restriction. And then a lot of what we do in the ultrasound unit or at the OB office is kind of trying to determine whether that baby is under the 10th percentile, but probably that’s fine and measuring smaller, or is it that baby that maybe isn’t sort of meeting their growth potential because of some other issue going on, whether the placenta is not at its optimal state or is there a maternal disease like hypertension or lupus affecting the size of the baby or maybe there’s something intrinsically wrong genetically or there’s a birth defect? There’s a lot of different things that can cause, through pathologic, maybe growth restriction.

So I think when we first make that diagnosis in the office, it’s kind of doing an initial workup to get as much information as possible. And I would say, most of the time, that workup is normal, right? I mean, most of the time we do a fetal assessment, and maybe mom doesn’t really have medical problems, or we just have this number that maybe the baby’s at the 7th percentile. And then we kind of use a few ultrasound markers to help us determine whether their overall utero environment is a big one.

Dr. Fox: Yeah. Wow. What a good explanation. See, very good. You lived it, you talk. No. Listen, I say the same thing. There’s a lot of terms and that’s part of the confusion. There’s fetal growth restriction, which is sort of a lot of people use instead of intrauterine growth restriction, though they basically mean the same thing. But like you said, both of them…the word restriction implies, like, something is wrong. Like, there’s a problem happening. The baby is supposed to be X, but it’s smaller than X. And that’s sort of how we think of growth restriction. But technically, all we’re doing is saying, “Your baby looks small,” right? So some people say small for gestational age, SGA. And so that’s probably more precise to say, “All right, your baby’s measuring small.” Again, we’re also not even weighing the baby. We’re measuring the baby. So we could even be wrong on the weight.

But, you know, let’s assume we’re right, and the baby is small. Most small babies, they’re like small adults. They’re fine. Like, you know, if someone is thin or someone is, you know, not tall, that doesn’t mean anything wrong with them. There’s a variation in human size, and there’s a variation in fetal sizes. And sort of the art is trying to figure out which of it are we talking. Is this a normal small baby, or is this a baby with potential problems? And if so, what are we going to do about it? Because those problems, some of them can have a lot of implications in the pregnancy or beyond. And so it’s sort of, like, we’re trying to, on the one hand, tell people we’ve identified a possible issue and be very thorough about it, but on the other hand, not scare them to death. And that’s a tight balance.

Since this is something we do every day and it’s obviously something you do every day, how does your personal experience of going through it sort of color how you talk about it with people? Like, do you tend to be more peppy positive because you went through it that way, or do you tend to be a little bit more cautious because you know what it could have been? You said that it colors how you talk to people. And first, how?

Dr. Naqvi: You know, it’s a really good question.

Dr. Fox: Thank you. That’s why this podcast is…you know, we’re killing it because of these tough questions, like, 60 minutes here. This isn’t softball. I’m throwing 100 miles an hour at you.

Dr. Naqvi: Yeah, it’s hard to articulate. I would say it’s a little bit of both. Well, I do tend to be more on the positive side, but I think that I’m probably more positive when I…I mean, I genuinely think it’s probably okay, you know, and there’s going to be things that are going to be specific to every specific case, you know, that may make you feel one way about it or another. So certainly, you know, we sometimes divide growth restriction into, you know, like, early onset growth restriction, right, or late-onset growth restriction. So, you know, these early cases that are more, like, higher to 32 weeks and then the late cases after 32 weeks. And so I would say, you know, especially patients that are diagnosed closer to term, you know, not very severely growth restricted with, otherwise, really reassuring findings, which is actually pretty analogous to what I experienced, taking away that it was the less than the first percentile. You know, I would say I’m pretty positive about it. And sometimes I even share my experience.

Dr. Fox: I was going to ask you how often you do…is that something you do routinely or just based on the person?

Dr. Naqvi: Yeah. I don’t do it routinely, mostly because I don’t know. I mean, sometimes, I’m kind of, especially, I think of myself as a patient, and then, like, gosh, I don’t want to say here my doctor’s experience. I’m here, freak out, you know. Like, I don’t really care. So I do it very sparingly, but you know, sometimes it seems appropriate and it feels like it might actually be reassuring to a patient who, you know, is really, really worried and most of the factors are reassuring.

The thing is the caveat to all of that is none of us are fortune tellers, right? I mean, we got numbers, we got statistics, and here I have some personal experience too, but we can’t predict what the outcome is going to be 100% of the time and be right 100% of the time. So, you know, we always…I have caution, I guess, when I counsel. And even when I’m optimistic, I mean, I remind my patients that there’s a reason why we’re doing the testing, right? I mean, yes, all the outcomes…I mean, most of the outcomes are generally good. I mean, statistically speaking, right? I mean, I usually say about 70% of babies that are measuring or actually even born under the 10th percentile have completely, completely normal outcomes, like, no NICU admission, go home with mom, normal follow-up.

And so that number is, you know, some people hear that and are like, “Oh, wow, that’s great.” And others hear that like, “What, only 70%?” You know? Like, that means, like, 30% are going to…something’s gonna happen. So everyone interprets those numbers a little bit differently. I guess that’s like a long-winded complicated answer to your question, but I think I share my story when I think it may be beneficial in some way to the patient. And the way that…actually, not even just the growth restriction part, maybe it’s just having had kids or just being a practicing patient. A lot of the practical questions, I think sometimes I feel more prepared to answer, I guess, you know. And then people ask like, “Oh gosh, does this mean that the baby’s automatically going to go to the NICU?” or, “Does this mean I’m going to not be able to nurse or something like that?” But I think I have…I don’t know if I would have been able to answer those questions as well before maybe, and now I feel a little more comfortable.

Dr. Fox: I mean, different, like you said, some patients do connect with their doctor’s own stories, other patients want none of it, and both are totally understandable. Like, different people are comforted by different things, and you know, sometimes you got to sort of figure that out, like, what they’re looking for story-wise. But, I mean, yours wasn’t exactly run of the mill because those percentiles are so small. Like, most people who are in this boat, so to speak, the percentiles are generally between, like, three and nine, and most of the time we’re pretty reassuring. The ones that are under one across the board, even though, yeah, probably it’s going to be okay, we’re always a little bit more worried. And that’s why, you know, twice weekly and delivering a little bit early and all this stuff, it’s…so, yeah. I mean, if you were your MFM, right, if you saw someone just like you under the first percentile and all this stuff, how cautious or how scary would your counseling be, right? It’s not run of the mill, but certainly, “Whoa, this is, hello, a pretty small baby.”

Dr. Naqvi: Yeah. I mean, you know, I think I tend to describe sort of the outcomes and the possibilities as they are, you know, in reality. And I think those are actually probably the patients that I do think sometimes it helps to, like, be a real live human in that scenario because…or sometimes when the baby’s measuring a little bit bigger, because then you’re sort of like, “Well, you know, sometimes these four or five pounders actually do fantastic.” And then sometimes they don’t. And it’s sort of like what the spectrum kind of looks like. So, I mean, I think, definitely, I’m very off, and I think that’s the most important part is to kind of describe what the worst-case scenarios kind of look like and then reassure that most moms are not going to end up with a baby in those worst-case scenarios, but it’s always possible. And I think knowing that it’s on the radar usually makes sort of the experience a little bit less scary.

Dr. Fox: Right. Yeah. Now, what happened with your other kids? Were they small?

Dr. Naqvi: No. So, you know, the second one, actually, my second one is a girl, and she was 6-13, which sounds not that big, but that’s two pounds bigger than my first.

Dr. Fox: That is big. That’s like a Naqvi and a half.

Dr. Naqvi: There you go. And then the youngest, my baby, was a boy. He was seven-four. So they got bigger and bigger. But, you know, the funny thing is, I remember, like, my first pregnancy was…I mean, you know, I think, a lot of first-time moms, you’re super responsible. I was, like, eating. That was healthy. And I was restricting my caffeine and, you know, I was working out regularly, but not too much, especially when the baby was starting to, you know, measure a little bit small. And I just thought I was like, “Well, we’re perfect patients.” You know, just out of like time limitations and being busy and chasing around a toddler, I was like, I think too, I kind of, you know, maybe not like that as much.

Dr. Fox: Took up smoking and ate chocolate all day.

Dr. Naqvi: Right. Well, I definitely had a lot more tea. I’m like an avid tea drinker, and I was really careful of not going over the limit for the first one. And the second and third, I just needed to stay awake. And then, you know, we kind of revisit some of those caffeine studies, I’m telling you. It just got bigger and bigger.

Dr. Fox: Yeah. It’s the New York/California thing, you know, New York, it’s just a very stressful environment and everything goes wrong. And California, you guys, it’s all chill. Everything’s great. There’s sunshine Everyone’s laid back, you know. It’s wonderful. Go figure. Wow. Awesome. Thank you so much for telling your story and talking to me and hanging out with us on the podcast. I really appreciate it. It’s great to catch up and I think it’s great for our listeners to get to know you. And hopefully, you’ll decide to move back to New York, and we’ll get to work together again.

Dr. Naqvi: Well, thank you so much for having me. Yeah, I know. I thought that’s what we were talking about.

Dr. Fox: Either-or. I’m whatever. It’s all good. It’s all good, whatever. We’ll figure it out, you know. There’s lots of years in front us.

Dr. Naqvi: You really got to visit at least. I mean, there’s so much to do here. I mean, the winter is coming. What are you going to do in December? Are you going to spend your December in New York? It’s going to be so cool.

Dr. Fox: Oh, I just like to stand here and be cold. It’s wonderful. So I’m from Chicago, so the winters here are not particularly concerning to me. Yeah. It’s beautiful. All right, Mariam, thank you so much.

Dr. Naqvi: Thank you so much for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in Healthful Woman is intended for educational uses only. It does not replace medical care from your physician. Healthful Woman is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.